For millennia, childbirth was the leading cause of death among women of reproductive age. While still an important cause of death, the leading killer worldwide is now HIV/AIDS, with the highest burden in sub-Saharan Africa.
There has been undeniable progress in the fight against HIV/AIDS. Rates of new HIV infections have been reduced by 6 percent since 2010, and more people than ever are now taking lifesaving antiretroviral treatment. When viewed from the perspective of women, though, the prognosis is not as bright.
Leading research and advocacy organizations are sounding alarms on stagnating and even rising infection rates in settings where adolescent girls and young women bear the greatest burden of new infections. But new prevention methods on the horizon, called multipurpose prevention technologies (MPTs), offer protection against HIV as well as an opportunity to simultaneously engage in family planning and reduce other sexual and reproductive health risks with discreet tools that are user-controlled.
One promising potential MPT, a vaginal ring that prevents HIV, is the focus of a set of articles in this week’s New England Journal of Medicine. These articles report the results of two parallel clinical trials testing vaginal rings containing the antiretroviral drug dapivirine in four African countries. In both trials, the rings were effective in preventing HIV when used according to protocol.
Today, several vaginal rings in early-stage clinical trials combine antiretroviral drugs with hormonal contraceptives to deliver combined prevention of HIV and unintended pregnancy. However, as Dr. Adaora Adimora cautions in a NEJM editorial, future interventions must take into consideration the different behavioral and contextual prevention needs of women in different stages of their lives.
No single solution meets the needs of all women. That’s why there are numerous innovative MPT designs under development. In addition to different vaginal ring designs, the pipeline includes innovative products such as fast-dissolving vaginal films, vaginal and rectal inserts, and vaginal and rectal gels that can address multiple risks. Some combine contraception with HIV prevention. Some combine contraception with protection against other sexually transmitted infections, including herpes simplex virus, which is common in many regions around the world, including the United States. Others prevent HIV and other sexually transmitted infections while allowing for conception.
Experts are also looking into co-packaging oral contraceptives with oral pre-exposure prophylaxis (PrEP), drugs that a woman at high risk for being infected with HIV can take daily to lower her odds of becoming infected with the virus.
Responding to global demand
More than 1,200 researchers, advocates, and funders from 15 different countries are engaged in the Initiative for MPTs (IMPT). This product-neutral global collaboration aims to advance the development and use of MPTs by providing critical infrastructure and guidance to the resource-limited MPT field.
MPT champions from around the globe, including China, India, Kenya, South Africa, and the United States, are using the IMPT as a platform to forge in-country collaborations that aim to make MPTs desirable for women who need them and accessible to them.
Combining separate prevention efforts into one product is a matter of efficiency. But it can also increase the number of women covered by the umbrella of prevention. In many areas of the world, women often prioritize their need for modern contraception over their need for HIV prevention. MPTs could provide a unique and critical way to leverage women’s need for — and willingness to use — contraception that also includes HIV and STI prevention.
The lingering stigma of HIV infection prevents many women from seeking HIV prevention. Combining prevention of HIV and sexually transmitted infections with contraception and delivering it in a family planning setting could increase the uptake of HIV prevention.
A host of positive outcomes flows from women being empowered to make decisions over their own bodies, which includes access to reliable and convenient methods of contraception and prevention of sexually transmitted diseases. Widespread use of MPTs can improve educational attainment for girls by preventing unintended pregnancies; improve economic attainment by allowing women to plan pregnancies and avoid infections; reduce mother-to-child HIV transmission; and decrease the number of high-risk pregnancies and births. Healthy mothers are better able to have healthy children.
As described in a 2015 Guttmacher Institute policy paper, the MPT field has received insufficient funding, especially compared to other health-prevention efforts. Research and development of new drugs commonly receive both public and private support while work on MPTs has received most of its funding from government agencies, both in the US and internationally. With the uncertainty surrounding the US government’s continued leadership role in prevention funding, there is a redoubled need for broader funding partnerships for MPTs.
By investing in MPTs — in better, more comprehensive prevention for women — pioneering funders can once again help put us on a path to end AIDS.
Bethany Young Holt, PhD, directs the Initiative for MPTs, a project of CAMI Health, an organization dedicated to women’s reproductive health and empowerment that is housed at the Public Health Institute in Oakland, Calif.
